Outcome after wait-listing for emergency liver transplantation in acute liver failure: A single centre experience

Background/Aims

Though emergency liver transplantation (ELT) is an established treatment for severe acute liver failure (ALF), outcomes are inferior to elective surgery. Despite prioritization, many patients deteriorate, becoming unsuitable for ELT.

Methods

We examined a single-centre experience of 310 adult patients with ALF registered for ELT over a 10-year period to determine factors associated with failure to transplant, and in those patients undergoing ELT, those associated with 90-day mortality.

Results

One hundred and thirty-two (43%) patients had ALF resulting from paracetamol and 178 (57%) from non-paracetamol causes. Seventy-four patients (24%) did not undergo surgery; 92% of these died. Failure to transplant was more likely in patients requiring vasopressors at listing (hazard ratio 1.9 (95% CI 1.1–3.6)) paracetamol aetiology (2.5 (1.4–4.6)) but less likely in blood group A (0.5 (0.3–0.9)). Post-ELT survival at 90-days and one-year increased from 66% and 63% in 1994–1999 to 81% and 79% in 2000–2004 (p < 0.01). Four variables were associated with post-ELT mortality; age >45 years (3 (1.7–5.3)), vasopressor requirement (2.2 (1.3–3.8), transplantation before 2000 (1.9 (1.1–3.3)) and use of high-risk grafts (2.3 (1.3–4.2).

Conclusions

The data indicate improved outcomes in the later era, despite higher level patient dependency and greater use of high-risk grafts, through improved graft/recipient matching.

Introduction

Emergency liver transplantation (ELT) plays a pivotal role in the management of acute liver failure (ALF), with little impact to date from alternative therapies including liver support devices and cell transplants [1], [2]. While survival rates appear acceptable, outcomes are consistently worse than for patients undergoing elective transplantation for chronic liver disease (CLD) [3], [4], [5]. The gap in the US is seven percentage points and in Europe it is up to 15 percentage points [4], [6]. Understanding the issues driving this survival differential would be beneficial for selection and management of candidates for ELT.

Key factors that influence patient survival include the timeliness of organ availability, clinical condition of the patient at time of transplantation, quality of the donor organ and standard of intra- and post-operative care [7], [8], [9]. Organ allocation systems prioritize patients with ALF with no obvious opportunity to accelerate progression to transplantation. Supportive care protocols are sophisticated and, again, immediate significant improvement is not anticipated. Therefore, the opportunity to improve results of ELT appears to rest on an ability to recognise futility of intervention and manipulate patient/organ matching to achieve optimal results.

The most comprehensive attempt to date to address some of these issues was a study of outcomes in 1457 patients transplanted for ALF between 1998 and 2004 in the US [10]. The overall mortality was 23%, and factors identified as correlating with outcome were body mass index (BMI), serum creatinine, age and the need for assisted ventilation. Survival decreased progressively with increasing number of adverse factors present but the worst observed outcome was 42% survival in a cohort that accounted for only 2% of the study population. This study did not consider the cumulative effects of adverse graft factors of likely importance in this setting [5], [11].

We report a single-centre experience of ELT in ALF over a 10-year period with specific aims of understanding why patients listed for ELT succumbed without being transplanted, and what factors were predictive of early death once transplantation had been performed.